Commencement

These Regulations shall come into force on the 1st day of April, 2004. MADE by the Minister of Human Development this 1st day of April, 2004. (SYLVIA FLORES) Minister of Human Development Social Service Agencies 101 SCHEDULE FORM I (Regulation 4(1)(a)) APPLICATION FOR A RESIDENTIAL CARE FACILITY FOR CHILDREN LICENCE FOR ALL NEW FACILITIES Date ___________________ Non-refundable application fee: $100.00 Name of Applicant: ______________ Telephone number: ___________ Legal Name of Governing Body: ________________________________ Mailing or home address: ______________________________________ Address of the residential care facility for children (if any): ___________________________________________________________ Telephone number at the residential care facility for children: __________ Type/s of Facility: Category 1 _____ Category 2 _____ Category 3 ____ Category 4 _____ Category 5 ____ Category 6 ____ (✓ as appropriate) Category 1 – a facility for abused, neglected, abandoned and/or orphaned children ages birth to thirteen years. Category 2 – a facility for abused, neglected, abandoned and/or orphaned children ages fourteen to eighteen years. Category 3 – a facility for children ages nine to fourteen who have committed status or summary offences. Category 4 – a facility for children ages fifteen to eighteen years who have committed status or summary offences. Category 5 – a facility for children ages nine to fourteen years who have committed an indictable offence. 102 Social Service Agencies Category 6 – a facility for children ages fifteen to eighteen years who have committed an indictable offence. Have you ever applied for or held a licence for a residential care facility for children before? Yes _____ No _____ (✓ as appropriate) If yes, for what reasons are you reapplying? ___________________________________________________________ ___________________________________________________________ Please complete the following information for the services you intend to provide□ I will be the operator and the provider at the residential care facility for children. □ I will be the operator of the residential care facility for children and employ providers. (✓ as appropriate) Capacity (number of children): __________ Age of children: __________ Staff/providers (names, qualifications and duties): ___________________ ___________________________________________________________ Has any staff member or provider been accused of child abuse? ________ Commencement date of proposed operation: _______________________ Size of land:_________________________________________________ Physical description of facility: (Please attach a floor plan, including measurements of rooms) Social Service Agencies 103 Please discuss the capacity of the residential care facility for children in detail, including the number of residents and sleeping arrangements for residents and staff. Numbers, size and types of beds used by residents Number and type of toilets and bathrooms Water Supply Excreta Disposal Number of residents for which it is desired that the residential care facility for children be licensed. (sexes and age groups, backgrounds) Outline the proposals for the following required programs: (a) Health; (b) Education; (c) Behaviour Management; (d) Counselling and Health and Family Life Education. What are the proposed recreational and leisure time opportunities that shall be afforded to residents? ___________________________________________________________ Other services offered: ___________________________________________________________ I have received a copy of: The Operational Manual for Residential Care Facilities for Children. _____Yes _____No The Social Services Agencies (Operators of Residential Care Facilities for Children) (Registration, Licensing and Minimum Operating Requirements) Regulations. _____ Yes _____ No (✓ as appropriate) 104 Social Service Agencies I understand that an interview/inspection is part of the application/reapplication process. I hereby give consent to allow access to the Registrar or his/her authorized representative to the residential care facility for children and records. I understand that any false statements contained herein will make me subject to certain penalties as set out in the regulations. I understand that notification of any changes regarding location, operator, services, capacity, or providers must be immediately reported to the Registrar and to the Ministry. ____________________ ____________________ Applicant’s Signature Date Licence #: ___________________ OFFICIAL USE ONLY: Fees collected: _________________ Date of Inspection: _____________ Interview and inspection: Enclosures: letters of reference _____, medical checks _____, criminal checks _____, child abuse checks _____ other information requested: ___ Social Service Agencies 105 FORM I (Regulation 4(1)(b)) APPLICATION FOR A TEMPORARY LICENCE FOR EXISTING RESIDENTIAL CARE FACILITIES FOR CHILDREN Date ___________________ Non-refundable application fee: $100.00 Name of Applicant: ______________ Telephone number: ___________ Legal Name of Governing Body: ________________________________ Applicants home address: ______________________________________ Applicant’s telephone number: __________________________________ Applicant’s fax number: _______________________________________ Applicant’s E-mail address: _____________________________________ Have you ever applied for or held a licence for a residential care facility for children before (in Belize or any other country)? _____ Yes _____ No (✓ as appropriate) If yes, Country where licence was issued: _______________________________ Length of time that licence was held: _____________________________ Was the licence ever cancelled or revoked? ________________________ If yes, please state reasons: ___________________________________________________________ Type/s of Facility: Category 1 _____ Category 2 _____ Category 3 _____ Category 4 _____ Category 5 _____ Category 6 _____ (✓ as appropriate) 106 Social Service Agencies (a) Category 1 – a facility for abused, neglected, abandoned and/or orphaned children ages birth to thirteen years. (b) Category 2 – a facility for abused, neglected, abandoned and/or orphaned children ages fourteen to eighteen years. (c) Category 3 – a facility for children ages nine to fourteen who have committed status or summary offences. (d) Category 4 – a facility for children ages fifteen to eighteen years who have committed status or summary offences. (e) Category 5 – a facility for children ages nine to fourteen years who have committed an indictable offence. (f) Category 6 – a facility for children ages fifteen to eighteen years who have committed an indictable offence. Please complete the following information for the services you intend to provide□ I will be the operator and the provider at the residential care facility for children. □ I will be the operator of the residential care facility for children and employ provider(s). (✓ as appropriate) Name and ages of the residents currently at the facility: ___________________________________________________________ Staff/providers (names, qualifications and duties) ___________________________________________________________ Has any staff or provider been accused of child abuse/neglect? ___________________________________________________________ Commencement date of operation: _______________________________ Size of Land: ________________________________________________ Social Service Agencies 107 Physical description of facility: __________________________________ (please attach a floor plan, including measurements of rooms) Please discuss the capacity of the residential care facility for children in detail, including the number of residents and sleeping arrangements for residents and staff. Numbers, size and types of beds used by residents Number and type of toilets and bathrooms Water Supply Excreta Disposal Number of residents for which it is desired that the residential care facili for children be licensed. (sexes and age groups, backgrounds) _________ Outline the proposals for the following required programs: (a) Health; (b) Education; (c) Behaviour Management; (d) Counselling and Health and Family Life Education. What are the proposed recreational and leisure time opportunities that shall be afforded to residents? ___________________________________________________________ Does any medical officer or public health nurse visit the facility regularly? (If YES, give name and addresses) ___________________________________________________________ Other services offered: ___________________________________________________________ I have received a copy of: The Operational Manual for Residential Care Facilities for Children. _____Yes _____No 108 Social Service Agencies The Social Services Agencies (Operators of Residential Care Facilities for Children) (Registration, Licensing and Minimum Operating Requirements) Regulations. _____ Yes _____ No (✓ as appropriate) Fees: ______________________________________________________ Other: _____________________________________________________ I understand that an interview/inspection is part of the application process. I hereby give consent to allow access to the Registrar or his/her authorized representative to the residential care facility for children and records. I understand that nay false statements contained herein will make me subject to certain penalties as set out in the Social Services Agencies (Operators of Residential Care Facilities) (Registration, Licensing and Minimum Operating Requirements) Regulations. I understand that this is an application for a temporary licence and that I have a grace period of three years to meet the minimum requirements set. ____________________ ____________________ Applicant’s Signature Date Licence #; __________ OFFICIAL USE ONLY: Fees collected: _________________ Date of Inspection: _____________ Interview and inspection: Enclosures: letters of reference _____, medical checks _____, criminal checks _____, child abuse checks _____ other information requested: ___ Social Service Agencies 109 FORM III (Regulation 4(1)(c)) RENEWAL APPLICATION FOR RESIDENTIAL CARE FACILITIES FOR CHILDREN Date ____________________ Non-refundable application fee: $50.00 Legal Name of Governing Body: ________________________________ Name of Operator: ______________ Telephone number: ___________ Mailing or home address: ______________________________________ Name and address of the residential care facility for children: ___________________________________________________________ Telephone number of the residential care facility for children: __________ Current licence number: __________ Date issued: __________ Expiry date: __________ Do you wish any change to be made to the conditions in your current licence? _____ Yes _____ No (✓ as appropriate) Please indicate any proposed changes below: Operator: __________ Provider(s): ______________________________ Location/address: _____________________________________________ Name of the residential care facility for children: ____________________ 110 Social Service Agencies Services offered: _____________________________________________ Type of licence: ____________________ Category of facility (1, 2, 3, 4, 5, 6): ____________________ I understand that an interview/inspection is part of the renewal process. ____________________ ____________________ Operator’s Signature Date Licence #: _______________ OFFICIAL USE ONLY: Fees collected: _________________ Date of Inspection: _____________ Interview and inspection: Enclosures: letters of reference _____, medical checks _____, criminal checks _____, child abuse checks _____ other information requested: ___ Social Service Agencies 111 FORM IV (Regulation 6(5)) NOTIFICATION OF INTENTION To: ______________________________ Date: _______________ (Name of Operator on Licence) Please take notice that pursuant to the powers vested in me under the Social Services Act, Chapter 45, and the Regulations made thereunder, I hereby give you notice that I intend to ____________________ Refuse to issue a licence to you ____________________ Refuse to renew your licence ____________________ Suspend your licence ____________________ Cancel your licence ____________________ Restore your licence to operate a residential care facility for children at: __________________ ___________________________________________________________ For the following reasons: ___________________________________________________________ ___________________________________________________________ And further take notice that under section 22 of the said Act, you have the right to appeal this matter to the Minister within 14 days of this notice. ___________________ ____________________ Signature of the Registrar/ or Date authorized representative 112 Social Service Agencies FORM V (Regulation 19(2)(a)) STATEMENT OF HEALTH OF RESIDENT I, ___________________________________________, have examined (Physician/Public Health Nurse name) _____________________________________ with the following results (Child’s name) Weight: __________ Height: __________ Blood pressure/pulse: __________ Temperature: __________ Heart: ____________________ Lungs: __________ General appearance and condition (cleanliness, skin rashes and discolorations, bloating, swelling, etc.) ___________________________________________________________ External signs of disease: _______________________________________ External signs of injuries and their location (burns, lacerations, bruises, scratches): __________________________________________________ Genital examination: __________________________________________ Anal examination: ____________________________________________ Other findings: _______________________________________________ Recommendations for follow-up treatment: ________________________ ___________________________________________________________ __________________________________ ____________________ Physician/Public Health Nurse Signature Date Social Service Agencies 113 FORM VI (Regulation 19(4)(d)) STATEMENT OF HEALTH OF PROVIDER/ASSISTANT/STAFF MEMBER I, ___________________________________________, have examined (Physician/Public Health Nurse name) _____________________________________ and have determined that (Name of provider, assistant/member of staff) he/she (circle one) is in good physical and mental health to care for residents at __________________________________. (Residential care facility for children) Weight: __________ Height: __________ Blood pressure: __________ Blood test: __________________________________________________ Urine Test: __________________________________________________ Stool test: ___________________________________________________ Chest X-Ray: ________________________________________________ Hepatitis: ___________________________________________________ History of medical conditions (epilepsy, diabetes, hypertension, etc.) ___________________________________________________________ Presence of communicable diseases: ______________________________ ___________________________________________________________ 114 Social Service Agencies External signs of Disease: ______________________________________ ___________________________________________________________ History of Mental Illness: ______________________________________ ___________________________________________________________ Other findings: _______________________________________________ Special considerations: _____ Yes _____ No (✓ as appropriate) ___________________________________________________________ _________________________ ____________________ Signature of Physician Date Social Service Agencies 115 FORM VII (Regulation 19(2)(b)) RESIDENTIAL CARE FACILITY FOR CHILDREN ADMISSION FORM Child’s name: ________________________________________________ Date of Birth: ____________________ Age: _____ Date and Time of Admission: ___________________________________ Reason for Admission: ________________________________________ Brief Description of Child’s Background/History: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Has the child been previously placed at a Residential Care Facility for Children? _____ Yes _____ No _____ Unknown (✓ as appropriate) If yes, Name of Facility: _____________________________________________ Length of Stay: ______________________________________________ Mother’s Name: ______________________________________________ Mother’s Address: ____________________________________________ Father’s Name: ______________________________________________ Father’s Address: _____________________________________________ Guardian’s Name (If different from Parent): _______________________ Guardian’s Address: __________________________________________ 116 Social Service Agencies Other Relatives Interested in the Child: Name Relationship Address ____________________ _____________ _____________________ Other Non-Relatives interested in the Child: Name Relationship Address ____________________ _____________ ____________________ Are there any person(s) not allowed to have contact with the child? _____ Yes _____ No (✓ as appropriate) If yes, Name Relationship ____________________ _____________________ Are there any person(s) allowed only supervised contact with the child? _____ Yes _____ No (✓ as appropriate) If yes, Name Relationship ____________________ ____________________ Type and duration of Legal Authorization: _________________________ Committing Judge/Magistrate and Jurisdiction: _____________________ Name of Social Services Practitioner or Police Officer accompanying child at the time of admission: __________________________________ Name of Social Services Practitioner with case responsibility: ___________________________________________________________ Comments: __________________________________________________ ___________________________________________________________ ____________________ ____________________ Name and Signature Date Social Service Agencies 117 FORM VIII (Regulation 19(2)(h)) HOME RELEASE FORM To: ________________________________________ (Name of Residential Care Facility) Child(ren)’s Name: _______________________ Age: _____ Sex: _____ Caseworker: ____________________________ Date: _______________ The abovementioned child(ren) will be released in the care of: Name: ______________________________________________________ Address: ____________________________________________________ Telephone number: ___________________________________________ Relationship to the Child: ______________________________________ AND □ Will be returned on __________ before 6pm. (Date) Responsibility for the general care of the child(ren) during this time lies with the abovenamed person. □ Will be placed for the purpose(s) of ______________________ and will not be returned. __________________________________ Authorized person of the Ministry 118 Social Service Agencies FORM IX (Regulation 38(2)(e)) SPECIAL INCIDENT FORM Name of Residential Care Facility: _______________________________ Date of Incident: _______________ Staff on duty at the time of the incident: ___________________________ Name(s) and age(s) of resident(s) involved in the incident: ___________________________________________________________ ___________________________________________________________ Detailed description of Incident: _________________________________ ___________________________________________________________ Action taken by staff on duty: ___________________________________ Was incident reported? _____ Yes _____ No (✓ as appropriate) If yes, Date: _______________ To whom: _____________________ Recommendations of staff on duty: _______________________________ ___________________________________________________________ Follow-up action needed: ______________________________________ Comments: __________________________________________________ ___________________________________________________________ __________________________________ ____________________ Name and Signature of staff completing Date Form Social Service Agencies 119 FORM X (Regulation 7(2)) LICENCE Type of Licence: _____ New _____ Temporary _____ Renewal Category(s) __________ Licence is granted to __________________________ to operate a residential care facility for children known as ______________________ located at _______________________________________ in the country of Belize, for a maximum of __________ residents for a period not exceeding ______ years. This licence commences on _____ day of __________, 20_____ and expires on _____ day of __________, 20_____. Given under my hand this _____ day of __________, 20_____. __________________________________ Signature of Minister 120 Social Service Agencies FORM XI (Regulation 19(2)(g)) CARE PLAN FORM Resident’s Name: _____________________________________________ Date of Birth: ________________________________________________ Date of Admission: ___________________________________________ Legal Status: ________________________________________________ Permanency Plan: ____________________________________________ Special needs: _______________________________________________ Goal Activities Time Frame Education: __________ __________ __________ Health: __________ __________ __________ Psycho-social: __________ __________ __________ Recreation: __________ __________ __________